Midwest Dysphagia Consultants MBSS Consultation Referral Form

MBSS Consultation Referral Form

Visit Information Step 1
Date

MonthDayYear
Date
Practice
Patient Location
Facility Name
City
State
Facility Phone Number
Format: (000) 000-0000.
Enter Address Where Patient Will be Seen (Fill all Sections)
Stay Type
Type of Stay

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Patient Information
Patient Name (Required)

First NameLast Name
Patient DOB (Required)

MonthDayYear
Date
Gender
Primary Contact Information for Scheduling i.e. nurse, caregiver, patient

First NameLast Name
Phone Number i.e. nurse, caregiver, patient
Format: (000) 000-0000.
Primary Insurance Type
Medicare Number(MBI)
Insurance
Insurances
Insurance Name
Policy Number

Step 3 of 7

Contact Information
Facility Speech Pathologist Name

First NameLast Name
Facility SLP Cell Phone Number Required to Receive Scheduling Notifications
Format: (000) 000-0000.
Email Address (Optional)
example@example.com

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Current Treatment for Dysphagia
Current Treatment

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MBSS Consultation Order
Order Given by Physician/NP/PA (ONLY VERBAL ORDER REQUIRED)

Ordering Provider First Name Ordering Provider Last Name
Only require verbal order to schedule our offices will contact to verify order in place
Verbal Order Received
Please submit your order by email to mdcoffice@proimagetx.com or fax at 513-713-0069 so we can get your patient scheduled.
Signature of Person Confirming Verbal Order with Credentials (SLP/Nurse/DOR/DON, etc. )
Printed Name of Person Verifying Verbal Order

First NameLast Name
Title of Person Verifying Verbal Order
Other Title
Order PI
Order MDC
- Esophageal scan-approx. 30% of pts have asymptomatic esophageal dysphagia, view esophageal emptying into the stomach Vocal cord assessment-for closure to protect against aspiration Mandibular/dental assessment-for of structural integrity/abnormalities and function for chewing/muscular support to evaluate the risk for choking with solids to determine the appropriate diet level Cervical spine/soft tissue assessment-for structural integrity/abnormalities and function, changes can lead to redirection of bolus increasing risk of aspiration and requiring a different level of strategy use Frontal chest view-for aspiration when aspiration occurs, allows for risk stratification for aspiration pneumonia The physician consult requested for dysphagia-impact of PO intake on prognosis, the impact of medication and anatomy, quality of life, and rehab candidacy discussion, recommendations for further consult.I Have Consent from the Patient or Legal Guardian

Additional Documents i.e. H&P, Medication List, copy of written order (Optional)

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MBSS Consultation Referral Form

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